Transitional Care Management

The Transitional Care Management program is a new program designed to offer coordination of care between you and your Primary Care Provider. You will receive an appointment notice to see your Primary Care Provider within 1-14 days as part of your discharge instructions from the hospital. A Health Coach or Care Navigator will call or email you within two business days of your discharge and call you each week and as needed for the first 30 days after your discharge. The Health Coach or Care Navigator will review your discharge instructions, medication changes and upcoming appointments. It is important that you keep your follow-up appointments and communicate your symptoms to your Health Coach or Care Navigator. If at any time you have questions, concerns or non-emergency health changes, please call your Health Coach or Care Navigator to assist you.

Although patients going home from the hospital are usually on the road to recovery, many are not functioning at 100% and often do not know what to do to get better.The Transitional Care Management program is a patient-centered, team-based approach to helping patients receive the best possible care as they transition from the hospital setting to their home.